The general public remains largely ignorant of the crisis that is befalling medicine today. In my conversations with physicians of various specialties over the past year I have come to realize that medicine is in trouble. Physicians as well as to a lesser degree, their NPP (Non-Physician Provider) associates, are between a rock and a hard place with little room to breathe. They are pressured from the private insurance sector as their professional decision-making increasingly falls prey to restrictions on care in the name of controlling costs
Increasing demands on providers for pre-approvals for, as well as documentation of care provided, are unrelenting in their reach and scope. These increased demands on the health care provider for non-clinical duties, in turn deprive patients of time that could better have been spent rendering clinical patient services.
In addition to this, patients who have no insurance of any kind are increasingly common secondary to rapidly escalating costs for health care insurance coverage. Physicians are, in my considerable experience there when they are needed, no matter the patients' ability to pay. However, whenever you render care (lay hands on a patient), the provider takes on malpractice risk irrespective of the patients' ability to pay.
I submit that the increasing inability of patients to obtain health insurance due to increasing insurance industry coverage restrictions and the burdensome financial cost to business/the individual (economic rationing), of providing/obtaining health insurance coverage, transfers risk and cost in a variety of ways away from the insurance industry. The absorption of these costs and the inherent risk of malpractice liability then, is placed squarely on the shoulders of firstly
the provider
whether the provider is compensated for that care
or not, and derived from that
the patient.
Negative Outcomes vs Malpractice/Negligence
The public, influenced by the media as well as the marketing campaigns of various organizations has been influenced to such a degree, that levels of customer expectations in the aggregate, are often unrealistic. The public needs to understand that their expectations may exceed that which is possible in some instances, based on a number of variables that differentiate one patient from another.
In the real world of everyday care provided at every level, there are no guarantees as to the results of the care that is provided. There are statistical probabilities that do describe anticipated outcomes based upon combinations of various illnesses in a given patient. These can and are described to patients as they proceed through the treatment process. There will however, always be variations in probabilities of positive vs negative outcomes, in particular as the acuity of a given patients circumstances increases.
These statistics related to illness are well documented, and are a source of informed consent provided by physicians and other health care professionals prior to care being rendered. Throughout the course of treatment, outcome probabilities often change as the patient variously responds, or fails to respond to treatment efforts. While those who provide clinical care are always vigilant for signs of trouble, providing medical care will never be as predictable as having your car repaired.
Patients in less than an average state of wellness, the chronically ill
these are the patients who are the greatest consumers of medical care. I've often said that the people that we see in the hospital are not a bunch of Olympic athletes. Many patients that we see in the hospital or the emergency dept. have little reserve, take a variety of medications and even when they are well, are walking a fine line between illness and health.
The Reality
In Cardiac Care for example, often the first time that a patient presents to the emergency department, and then to the cardiologist, he/she is often in a very acute state of illness. The patient may be taken emergently to the cardiac catheterization laboratory and perhaps subsequently, to emergency cardiac surgery by the cardio-thoracic surgeon and their team. In each case, the physician and the health care team are working against time, and difficult circumstances, that sometimes do not result in a desirable outcome.
In Trauma Care, (another high risk specialty), again time is of the essence in correctly diagnosing the nature and degree of injury initially, and then proceeding with appropriate treatment. Decisions must often be made quickly, often without benefit of knowing a patients' previous medical history or other information that may be pertinent.
In that "golden hour", injuries may not "declare" themselves promptly, despite the full battery of diagnostic tests that are integral to the standards of trauma care. In these circumstances, outcomes may again be less than perfectly clear, even to the most experienced physician This is a risky occupation, even for the best in the business.
The family of a given patient in one of these situations that does not end well, may feel that just because the outcome was unfavorable, that not everything was done for their loved one and that there "must be" someone at fault somewhere. This despite having the best medical care that could possibly be provided completely in line with recognized standards of care But for those who provided the care... they are at risk.
In a number of states such as Florida, there are few impediments to filing suit in such circumstances. As long as there is a negative outcome, there will be an attorney willing to take the case. In Florida, it is particularly simple and inexpensive to bring suit against providers of medical care.
Physicians in accepting the risk of providing care to the very sickest patients, e.g., cancer, who in the worst of circumstances may have the least chance of survival, take on added risk in these situations. Then, when the outcome is less than satisfactory, a lawyer may be summoned and with a negative outcome in hand a malpractice suit may be filed.
The malpractice insurance carrier in seeking to control costs then seeks to "settle" the case. Who pays the price? We all do! In a variety of ways
That physician who most probably did nothing in error
who was merely the victim of a patients' inability to survive
there is exacted from he or she, an increase in their malpractice premiums as the settlement check is cut
saving the malpractice insurance carrier the cost of summoning their staff of attorneys to defend the appropriateness and the quality of care, provided by the physician so accused.
The Shared Cost of this System
Those physicians willing to give the most gravely ill a chance at life, are becoming fewer and fewer. I have spoken with physicians who described to me their experience in caring for such patients, knowing full well that despite their best efforts, the potentially poor outcome that was the likely result (due to the patients' grave condition on presentation), could very well end in a medical malpractice lawsuit.
Such anecdotes are not at all uncommon. Increasingly you hear the frustration from the physicians about the system as it now stands. They speak of early retirement. Currently, a very few physicians may decline to take certain more challenging, and there for less predictable cases, which are by definition, more risky relative to outcome and potential for malpractice concerns. This may leave you and I, the patient, without the best possible care in our time of need.
While the impact of this situation currently is minimal, in the future it will matter not if you are wealthy or poor, if the specialty physician that you are in need of is unavailable at the time you need it
where you need it
you will be out of luck. You may if you have the resources, be able to travel to the physician that you need, however such travel may entail risks depending on the nature and acuity of your illness. When you are really sick
you need to be seen NOW
not hours from NOW! We must not sit idly by and allow this situation to continue on its present path.
Premature Retirement
No Replacements
As the frustration grows among doctors, the public should be concerned. Who in our community will replace a specialty physician who chooses to retire early because of malpractice risk concerns, when they still have years of practice remaining in their professional life? I do not know about you but as a provider of quality health care, I do not find this to be acceptable.
Early retirements of valuable physicians out of frustration with the non-clinical aspects of practice represent only the tip of the iceberg as far as cost is concerned. The true cost lies somewhere out in the future. I submit that this "future" cost will begin to declare itself in the next 10 to 15 years, though the evidence of this "future" cost can be seen today in various medical specialty residency programs, which now are increasingly riddled with vacancies where once there were none.
Dr Lazoff of Project EINO writes "the real downfall is in the talented young residents and medical students who choose their commitment based on predictions of insolvency rather than community need, inherent talent or rewarding service. While Dr. Lazoff states this fact in his paper, I have heard from my physician colleagues about the difficulty of filling residency positions in the more risky and litigation prone specialties.
This problem will begin to impact Americans severely as the most mature cohort of physicians in specialties such as neuro and cardio-thoracic surgery, general and vascular surgery, cardiology, emergency medicine, and OB/GYN physicians begin to retire. There are additional specialties not listed though equally adversely affected.
Recognizing that there are significant periods (6-8 years or more) of training in all of these areas beyond primary medical residency. These physicians will not just appear out of thin air, although we do increasingly have foreign physicians who emigrate to the U.S., filling vacant positions. We must also train our own physicians in order to meet demand, and in order to do so, we must address this problem now.
In order to address this problem, we must remove the barriers to students entertaining medicine as a career, and in particular taking on the challenge of choosing the most acute areas of medicine where the needs are greatest. We must return to the day when newly minted medical residents chose their area of specialty based upon talent and desire, rather than minimization of malpractice risk.